Steven Peskin MD's blog

Alice found a Wonderland.

What we found last week, when the Center for Medicare & Medicaid Services (CMS) released cost information for the 100 most common diagnoses and procedures in over 3,000  hospitals, is beyond Alice’s imagination. Some of the cost differences for the identical billing diagnoses qualify for “you cannot make this stuff up.”

Two examples:

• Joint replacement in Ada, Okla.: $38,000; in Monterey Park, Calif.: $223,000
• Severe sepsis with mechanical ventilation for more than 96 hours: Bronx Lebanon Hospital in New York City, $38,000; Stanford Hospital, Stanford, Calif.: $637,000

Jonathan Blum, deputy administrator and director of the Center of Medicare at CMS, stated that making this information available to the public at no charge will put pressure on expensive hospitals. But will it?

Though CMS has the clout to make cost information available to the public, the average consumer has great difficulty finding out the cost of medical services, procedures, tests. A physician colleague who gave hospital grand rounds recently described his own significant challenge as he attempted to find the cost of hospital imaging and of an outpatient procedure for a family member.

The underinsured and uninsured are most vulnerable to excess list prices. That said, these astounding — and unsupportable — charge differentials demonstrate one of the key factors that the readership of Managed Care recognizes to be contributing to our broken health care system.

CMS has given us some ammunition in the battle for price and charge transparency in health care services. Let’s advance the campaign and reflect more clearly through the looking glass.

(Note: The author holds a position with a New Jersey health plan.)

We know Watson, the supercomputer, for its vast fund of knowledge and thinking prowess when machine bested man, defeating the all-time Jeopardy champ for games won, Ken Jennings (74), and Brad Rutter, Jeopardy’s highest money winner ($3,470,102), and winning against Jennings in a head-to-head Tournament of Champions. Now, Watson is flexing her considerable problem-solving muscle in medicine, and, more specifically, in clinical decision support. Indeed, the British edition of the online magazine Wired reports that “IBM’s Watson is better at diagnosing cancer than human doctors.” 

In September 2011, IBM and Wellpoint announced an agreement to create the first commercial applications of the IBM Watson technology to improve patient care. Watson has been a diligent medical student for the past two years, with a voracious  — perhaps insatiable  — appetite for both structured and unstructured data, including human language. Read more »

Earlier today, I was speaking with a physician colleague about his commitment to continue to improve person-centered care in his primary care practice and to enhance patient experience. We talked about the potential value of greeters in the practice, of a patient council to offer feedback and recommendations, and, with training, increasing the scope of service of medical assistants to allow nurses, advanced practice nurses, and physicians to spend more time with more complex care.

When reflecting on his comments about gracious greeters and coaching non-clinical and clinical staff on communication, I was reminded of a video from many years ago of the former CEO of Ritz Carlton that started with his passion and conviction about the importance of "a warm and sincere greeting." When Apple was entering the retail arena, Steve Jobs benchmarked Ritz Carlton for Apple retail stores to emulate for the ultimate in customer service.

Though the  "Consumer Assessment of Healthcare Providers and Systems" (CAHC) with all of iterations of home health, hosptials, health plans, ambulatory care, and, most recently medical homes, is frequently cited by health plan and health system leaders, adminstrators and clinicians, we are inconsistent at best in our abilities to deliver on good service. We point to the complexity (sometimes self-induced) of health care and the pain, discomfort, anxiety and/or fear that people may be facing in their interactions with health care workers (true, but not always), and, the time pressures that we face (nearly universal in today's hurried culture).

We should not hide behind excuses. A warm and sincere greeting is only a beginning, but it is certainly a great way to begin!

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School, and is Governor, American College of Physicians, New Jersey South.

In April of last year, I wrote about the first release of recommendations from the American Board on Internal Medicine Foundation in conjunction with nine medical societies as part of a campaign: Choosing Wisely. The campaign aims to draw attention to and call into question commonly ordered tests like chest x-rays before surgery, frequently performed procedures like colonoscopies, and frequently prescribed treatments like antibiotics for upper respiratory infections. The campaign is directed to clinicians and patients with both audiences asked to consider the evidence for not doing select tests and procedures in specific circumstances where the evidence supports not doing the test or procedure or treatment. 

Fast forward 10 months. The ABIM Foundation has released 90 more recommendations in conjunction with medical specialty societies for physicians, other clinicians, and patients/consumers asking us to consider the evidence and to choose wisely. We should applaud the ABIM Foundation, the National Physician Alliance, Consumer Reports and the dozens of medical specialty societies that have assumed the mantle of leadership to bring this information to health care professionals and to consumers in clear, crisp, and concise statements. 

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

With apologies to James Taylor, I was recently introduced to a UNC-Chapel Hill professor of psychology, Dr. Edwin Fisher, from my alma mater and the university where the famous singer/ songwriter's father was dean of the School of Medicine. The work that Dr. Fisher is doing under the aegis of the American Academy of Family Physicians Foundation is on target for the Triple Aim.

Peers for Progress, designs, implements, and evaluates peer coach or peer educator programs worldwide. There are ample examples of successful and established programs led or facilitated by peer coaches, motivators, educators, or others, including Alcoholics Anonymous, Mended Hearts, and Weight Watchers. Peers for Progress is building a global network of peer-support organizations that are making a difference in the health of and lives of people affected by a range of health problems and their associated impact on the individual and on communities.

Peer support / peer coaching is truly a winning proposition with benefits to the coached, to the coaches, to better health and health care, and the price is right!

Peers for Progress:

http://www.aafpfoundation.org/online/foundation/home/programs/education/peersforprogress.html#.UQGC26xu48Q.email

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

Though the title might apply to many aspects of our daily lives and the world as a whole, in this instance I am referring to how Medicare and other insurers interpret the word reasonable to make coverage and payment decisions. A recent editorial in the New England Journal of Medicine highlighted this enduring challenge for Medicare.

The authors begin with language from the Social Security Act:

No payment may be made. . . for any expenses incurred for items or services which . . . are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

The editorial takes the point of view that a legislative fix is needed for greater specificity surrounding reasonable and necessary services for coverage and payment determination. My view is that more complete definitions of reasonable and necessary —  definitions that might include "cost-effectiveness" or "adequate evidence" as the authors advocate — are not a meaningful part of the solution to Medicare's looming insovency and to addressing unsustainable cost increases.

But the authors note that "some may hope that the federal government can simply delegate coverage decisions to other parties, such as accountable care organizations, while forcing patients to consider the value of technologies through increased cost sharing." 

These two approaches are the path to the practice of cost-conscious care by clinicians and to cost-aware care among consumers.

The ability of providers to challenge evidence-based decisions with additional or alternaitve evidence when the economic incentives support volume over value has circumvented and will continue to circumvent payer efforts to control overuse. Aligning the collective interests of clinicians and their patients away from overuse and toward appropriate  care is the road to affordable health care.

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School.

As a baby boomer moving through middle age into the unspeakable age that follows “middle,” I was encouraged to read an article in the British Medical Journal that states that for seniors and super seniors, healthy behaviors that include regular exercise, not smoking, maintaining a normal Body Mass Index, and having a rich or moderate social network led to significant increases in longevity. From the study:

“Even after age 75 lifestyle behaviours such as not smoking and physical activity are associated with longer survival," the study authors write. "A low risk profile can add five years to women's lives and six years to men's. These associations, although attenuated, were also present among the oldest old (≥85 years) and in people with chronic conditions."

This study affirms the benefits of lifestyle and healthy behaviors for the hundreds of millions of people who are in or are entering their golden years in the United States and across the industrialized world. With these “prescriptions” or interventions, there is no need for elaborate quality-adjusted life year studies or comparative-effectiveness research to justify hundred-thousand-dollar sickness care interventions! The ROI is compelling.

Shaping or modifying our own personal behaviors or effecting positive health behaviors in others, whether as a health plan, an employer, or as clinicians, is no piece of cake but is well worth the effort.

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School.

A close friend of ours went with my wife to see a highly regarded physician for a persistent problem. This master clinician started with a warm greeting and a brief conversation about family, and then went through a detailed history of the problem that our friend had experienced for several months. He gave her an explanation of what he believed to be the underlying cause of her symptoms, gave a prescription for lab tests, and prescribed two medications. He also suggested that she see an ENT and recommended someone.

Our friend’s father had already recommended an ENT. The father, who happens to be a physician, had seen this ENT as patient.

 The contrast was stark. The physician was curt, made no effort to establish rapport, made a passing negative comment about the other physician’s medication selection without suggesting an alternative or the rationale for his disagreement, performed a 5-minute procedure of visualizing the inside of the nose (nasocopy), and, in closing, said “How do you breathe through that thing?? You should have it fixed.”

He charged $625.00 for the 5-minute procedure and $225.00 for the office visit.

The first physician followed up by phone, showed concern, and made recommendations about where our friend could follow-up within her health plan network.

Our friend, Doctor Smith (his real name), consistently shows genuine human interest, brings to bear keen diagnostic acumen, answers questions, and coordinates care. He has practiced this way for many years with patients from the C-suite and from homeless shelters. In sharp contrast is Dr. Rude, not his real name, who, sadly, gives our profession a black eye. Let’s reward and value the Doctor Smiths and devalue the Dr. Rudes.  Our provider networks, payment system, and, consumer information should align accordingly.

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

Amanada Bennett, a Pulitzer Prize winning journalist, chronicles the poignant journey that she and her now deceased husband, Terrence Foley, traveled in his seven-year battle with a rare form of kidney cancer. The Cost of Hope puts into sharp focus the convoluted compexity of our health care system even for two well educated, well insured individuals with superior skills to acquire, parse and synthesize information and data.

A recent experience helping a friend with advanced cancer to navigate within two large, highly rated health care systems brought home in a very personal way the frustration and fear that our sometimes seemingly impenetrable “system” may evoke. Like the Bennetts, my friend was well informed, well insured, and had superior abilities to access and analyze infomation about his own illness.

The cost in the Cost of Hope is financial as well as emotional. Over the past few days I have asked fifteen people — nurses, physicians, and non-health-care professionals, “How many CT scans do you think that a person with a diagnosis of kidney cancer received over seven years?” (Before you read further, make your estimate.)

My informal polling of these 15 people was 18 to 30.  Amanda Bennett and her husband decided to pore over the reams of information that they had received from insurers and providers to satisfy their curiosity about the number of CT scans performed. To their astonishment, the number was 76. Though the book does not do an evidence-based retrospective analysis of the appropriateness of each of these scans, the author's perception, shared by the 15 people that I polled, is that a substantial number of these scans were unnecessary.

In the aim for the Triple Aim, we were 0 for 3. For an excerpt, please link to the article below:

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=avRFGNF6Qw_w

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

The May 17 New England Journal of Medicine 200th Anniversary edition article The Evolving Primary Care Physician highlights key structural, financial, and cultural challenges that confront primary care in the United States. Some of these include training and education that emphasizes ever greater subspecialization, reimbursement that rewards volume versus value, and an increasing reliance on testing versus well-honed history taking, physical diagnosis, and counseling and coaching of patients and their family members/care givers.

The article touches upon research conducted by Christine Sinsky and Thomas Bodenheimer, supported by the American Board of Internal Medicine Foundation,  in which they visited and observed 23 primary care practices.  A compelling distillation from Dr. Sinsky:

What I’ve really seen is a lot of waste within the health care system at the level of utilization of physician skills. I think two thirds of many [primary care] physicians' days are spent on documentation, administrative tasks, paper work completion, rote inbox management, data gathering, and data entry. It’s something that is hard to recognize when you’re the one doing it.

To re-invigorate primary care, training needs greater emphasis on history taking skills, motivational interviewing, physical diagnosis, synthesis of information, more judicious use of testing and imaging, and engaging patients in their health care.

For primary care clinicians to enjoy professional satisfaction and improve population health management, and to reduce primary care clinician time on administrative functions, team-based care is a powerful prescription for positive change.

Douglas Kelling, a general internist in Concord, North Carolina, is profiled in the article as a successful example of transformation to team-based care. Kelling’s personal analogy is to make medical care "more like NASCAR with the doctor as the driver and other team members responsible for the fuel and tires.”

Dr. Kelling’s practice is effective caring for a large population, including patients with multiple chronic conditions.

Emerging health plan and CMS models that provide payments for care coordination and outcomes-/ performance-based payments will result in many new primary care-anchored teams through the country.

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.